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| Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS) study: a prospective population-based sequential comparison |
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October 2007
The risk of recurrent stroke is up to 10% in the week after a transient ischaemic attack (TIA) or minor stroke. Modelling studies suggest that urgent use of existing preventive treatments could reduce the risk by 80–90%, but in the absence of evidence many health-care systems make little provision for this.
In the recently published EXPRESS study, investigators aimed to determine the effect of more rapid treatment after TIA and minor stroke in patients who are not admitted directly to hospital.
Prof Peter M. Rothwell, from the Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK, and his colleagues did a prospective before (phase 1: April, 2002, to Sept, 2004) versus after study (phase 2: Oct, 2004, to March, 2007) of the effect on the process of care and outcome of more urgent assessment and immediate treatment in clinic, rather than subsequent initiation in primary care, in all patients with TIA or minor stroke not admitted directly to hospital.
The study was nested in a rigorous population-based incidence study of all TIA and stroke (Oxford Vascular Study; OXVASC), and case ascertainment, investigation, and follow-up were therefore complete and identical in both periods. The primary outcome was the risk of stroke within 90 days of first seeking medical attention, with an independent blinded (to study period) audit of all events.
Of the 1,278 patients in OXVASC who presented with TIA or stroke (634 in phase 1 and 644 in phase 2), 607 were referred or admitted directly to hospital, 620 were referred for outpatient assessment, and 51 were not referred to secondary care. 95% (n=591) of all outpatient referrals were to the study clinic. Baseline characteristics and delays in seeking medical attention were similar in both periods, but median delay to assessment in the study clinic fell from 3 days (interquartile range [IQR] 2–5) in phase 1 to less than 1 day (IQR 0–3) in phase 2 (p<0•0001), and median delay to first prescription of treatment fell from 20 (8–53) days to 1 (0–3) day (p<0•0001). The 90-day risk of recurrent stroke in the patients referred to the study clinic was 10.3% (32/310 patients) in phase 1 and 2.1% (6/281 patients) in phase 2 (adjusted hazard ratio 0.20, 95% CI 0.08–0•49; p=0.0001). There was no significant change in risk in patients treated elsewhere. The reduction in risk was independent of age and sex, and early treatment did not increase the risk of intracerebral haemorrhage or other bleeding.
The investigators concluded that early initiation of existing treatments after TIA or minor stroke was associated with an 80% reduction in the risk of early recurrent stroke. They recommended that further follow-up is required to determine long-term outcome, but these results have immediate implications for service provision and public education about TIA and minor stroke.
Reference:
Lancet 2007; 370 (9596): 1432–1442.
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